What are the recommendations for starting Eliquis (apixaban) in a 90-year-old woman with a pulmonary embolism (PE)?

Recommendations for Starting Eliquis in a 90-Year-Old Woman with Pulmonary Embolism

A direct oral anticoagulant (DOAC) such as apixaban (Eliquis) is recommended as the first-line treatment for a 90-year-old woman with pulmonary embolism (PE), with specific dosing of 10 mg twice daily for 7 days followed by 5 mg twice daily. 1, 2

Initial Assessment and Risk Stratification

Before initiating treatment, assess:

• Hemodynamic stability (blood pressure, heart rate)
• Renal function (creatinine clearance)
• Bleeding risk factors
• Drug interactions
• Fall risk

Risk Assessment Tools:

• PESI (Pulmonary Embolism Severity Index) or sPESI (simplified PESI) to determine mortality risk
• Assessment of right ventricular function via imaging or biomarkers

Anticoagulation Recommendations

First-line Treatment:

• Apixaban (Eliquis): 10 mg orally twice daily for the first 7 days, followed by 5 mg twice daily 3, 2

Important Considerations for Elderly Patients:

1. Renal Function Assessment:

   • Mandatory before initiating apixaban
   • If creatinine clearance <30 mL/min, unfractionated heparin may be preferred initially 3

2. Dose Adjustments:

   • Consider dose reduction to 2.5 mg twice daily after 6 months for extended therapy 1
   • Dose reduction should be considered if the patient has at least two of:
     • Age ≥80 years
     • Body weight ≤60 kg
     • Serum creatinine ≥1.5 mg/dL 2

3. Monitoring:

   • No routine laboratory monitoring required for apixaban (unlike warfarin) 3
   • Regular clinical follow-up recommended at 3-6 months 1

Duration of Treatment

• Minimum treatment duration: 3 months 3
• Extended anticoagulation (>3 months) should be considered for:
  • Unprovoked PE
  • Persistent risk factors
  • Recurrent PE 3
• For elderly patients who tolerate the initial 6-12 months without bleeding complications, long-term anticoagulation may be beneficial even with fall risk 4

Special Considerations for Elderly Patients

• Advanced age is not a contraindication to anticoagulation therapy, but requires careful monitoring 4
• Balance the higher risk of recurrent VTE in elderly against increased bleeding risk
• Fall risk alone should not preclude anticoagulation if otherwise indicated 4
• Consider reduced dose of apixaban after 6 months for extended therapy 1

Practical Management Tips

• Temporary interruption of apixaban:
  • Stop at least 48 hours before procedures with moderate/high bleeding risk
  • Stop at least 24 hours before procedures with low bleeding risk 2
• Restart as soon as adequate hemostasis is established 2
• Avoid abrupt discontinuation without alternative anticoagulation due to increased thrombotic risk 2
• Ensure patient understands the importance of medication adherence and bleeding precautions

Follow-up Recommendations

• Routine clinical evaluation at 3-6 months after PE diagnosis 1
• Assess for signs of chronic thromboembolic pulmonary hypertension (CTEPH)
• Evaluate need for extended anticoagulation based on risk factors and clinical course

DOACs like apixaban offer advantages over traditional vitamin K antagonists for elderly patients, including fixed dosing, fewer drug interactions, and no need for routine monitoring, while maintaining similar efficacy with potentially improved safety profiles 5, 6.